Reproductive experiences and factors influencing contraceptive use among female head‐porters in Ghana: A cross‐sectional study

Abstract Background and Aims Female head‐porters are a cohort of women who have migrated from their rural communities into commercial cities in search of better economic opportunities. These young women are vulnerable to untoward reproductive experiences. The study assesses the reproductive experiences of women and the factors influencing contraceptive use among them. Methods A cross‐sectional study was conducted from January to May 2021 in the Kumasi Metropolis (n = 280). The study included 280 female head‐porters within the reproductive age of 15–49 years. Convenience sampling and consecutive recruitment were used to obtain the needed sample size. All statistical significance was declared at a p‐value of <0.05. Results Forty‐two percent of respondents had a history of contraceptive use (all modern or artificial contraception). The study found gravidity (p < 0.0001), parity (p < 0.0001), number of sexual partners post‐migration (p = 0.008), and age of first sex (p = 0.033) to be associated with contraceptive use among female head‐porters. Conclusion Fourteen percent had experienced sexual exploitation post‐migration, the first sexual encounter of one‐third of participants were nonconsensual, 19% had sex at or before 16 years, and 72% were aware of contraception. Reproductive experiences such as gravidity and sexual debut (age at first sex) have a significant influence on the use of contraception.


| INTRODUCTION
The Sustainable Development Goals (SDGs) acknowledge the importance of access to sexual and reproductive health care. SDGs 3.7 and 5.6 place a premium on ensuring that everyone has access to family planning, information, and education, as well as other sexual and reproductive health services. 1 In line with the agenda 2030, there is an urgent need for global sexual and reproductive health education and promotion among migratory adolescent girls. This is necessary since migration is a significant worldwide policy issue and increases the risk of poor outcomes for females' sexual and reproductive health. 2,3 Globally, there are 740 million internal migrants, which makes this demand even more pressing. In urban areas of developing countries, adolescent girls make up 80% of this group. 4,5 Migration has become an essential part of human social life due to economic disparities across the globe, regions, or nations. Even in the same country, inequitable distribution of socioeconomic and educational opportunities causes people to move from one part of the country to the other. 6 Internal migration to Ghana occurs in all directions. 7 Migration from the north to the south, however, is more common and is associated with health and socioeconomic implications. Internal migration is so common that almost every northern woman is expected to migrate south at least once in their lifetime in search of better economic future. 8 Female head-porters are a cohort of women who have migrated from their rural towns into commercial/urban cities in search of better economic opportunities. This internal migration involves young women moving from their places of origin or livelihood to destinations across geographical boundaries within the same country. 9 Female head-porters are locally referred to as Kayayei (Kayayo for singular). "Kaya" in Hausa means luggage, load, or goods, while "yei" in Ga language means females. Their name literally means a young woman who carries luggage, goods, or a load for a fee. They usually help carry heavy loads of goods from bus stations and markets to various destinations for a negotiated fee. 8 They therefore aggregate at the large market centers of the city during working hours awaiting offers. Most of these head-porters are young females with low level of education. 10 Half of these migrants have either no education at all or have had only primary education 9 and want to save money for future investment or marriage. Previous studies show most of these migrants do not intend to be in the business for long but see head porterage as a stepping stone to better investment in the future. 11 Movement of these young women has both positive and negative effects on their personal lives and the society at large.
Even though some may have an improvement in their personal incomes, they may suffer from many dire consequences which may affect their future and health. 12 These negative consequences and outcomes of migration may impact negatively on their reproductive health and rights as well. There is a perceived increase in unstable sexual unions, unintended pregnancies, and unsafe abortions among these women compared to the general population. 13 It is also believed that access to effective and safe contraception is low among them. Unintended pregnancy and abortion have been closely linked to contraceptive use and certain socio-demographic indicators such as literacy and level of urbanization. 14 Female head-porters may not have access to modern contraceptives as they are usually beyond the reach of reproductive health advocacy programs. Previous studies show that among Kayayei, sexual violence was a common phenomenon, and even for consensual sex, their partners often object to the use of contraception. 15 In 2015, the Government of Ghana drafted a policy whereby there was commitment by all stakeholders to increase the modern contraceptive prevalence rate to 30% among married women and 40% among unmarried sexually active women by 2020, according to the Ghana Family Planning Costed Implementation Plan in 2016-2020. There was no national survey at the end of the program to evaluate the outcome of the costed implementation program.
However, according to the recent Ghana Maternal Health Survey which was done in 2017, the modern contraceptive rate was 25% among married women and 31% among unmarried sexually active women. These prevalence rates, though an improvement, still fall below expectations. According to the Metro Health Directorate at the study site, task sharing has been used to provide contraceptive services to difficult-to-reach population such as female head-porters.
Community health nurses who visit homes for immunization are therefore trained and mandated to offer contraceptive services as well. Most public health studies among the female head-porters in the Kumasi Metropolis had been based on malaria and musculoskeletal pains with less emphasis on their reproductive health experiences. 16 The few studies on reproductive health among female head-porters were mostly qualitative studies. Data pertaining to the reproductive experiences of these vulnerable women is limited, especially in Kumasi. This study therefore assesses reproductive experiences and factors influencing contraceptive use among Ghanaian female head-porters.

| Study design
This was a cross-sectional analytical study that took place from January to May 2021. This was the most feasible and cost-effective design to answer study questions and evaluate study objectives within the given time period. The study determined both independent and dependent factors at the same time.

| Study site
This study was conducted in the Asokore Mampong Municipality and Kumasi Metropolis. Kumasi is the second largest city in the middle half of Ghana. Market centers in the metropolis used for this study included Bantama market, Kejetia market, and Racecourse market.
The residencies of female head-porters are in the slums and deprived areas of the city. Some of these areas do not have potable water, access roads, health facilities, or security. Their living and sleeping places do not provide privacy for these girls. The majority of the places of residence of female head-porters have no access to mass media. The market centers where they trade have information centers. These information centers, however, hardly provide information on reproductive health but are usually used for advertisement of goods sold at the market and for religious activities.

| Study population
The study's population included female head-porters whose ages were between 15 and 49. They are also referred to as "Kayayei" or "paa-o-paa" in the local dialect. They have low socioeconomic status and thus migrate to the cities in search of greener pastures. In their bid to make some income, they are compelled to carry head-loads of goods from place to place around markets and bus stations for a fee.

| Inclusion/exclusion criteria
This study included female head-porters within the reproductive age of 15-49 years.
However, female head-porters who speak languages that cannot be understood by the research team, those who have spent less than a year in the city post-migration, and those unable to give informed consent to participate in the study were excluded from the study.
Also excluded from the study are those not certain of their age.

| Sample size calculation
Sample size was obtained using the formula: where n is the minimum sample size, P is the estimated value for the proportion of contraceptive use among Ghanaian females = 18.3%, 17 Taking into consideration 15% nonresponse rate and to increase statistical power, 280 participants were recruited for the study.

| Ethical consideration
Ethical approval for this study was granted by the Committee on

| Sexual and reproductive experiences
From the study, about 14% had experienced sexual exploitation post-migration. About one-third of study participants report that their first sexual encounter was nonconsensual. Furthermore, 19% had sex at or before 16 years and 72.1% were aware of contraception (Table 2).

| Contraceptive among female head-porters
Of the 202 participants aware of contraception, 85 (42.1%) had history of contraceptive use while more than half (57.9%) had no history of contraceptive use ( Figure 1). The commonly used contraception in descending order of use were injectables (47%), implants (26.8%), and pills (19%).
Moreover, of the 85 respondents who had used contraceptives before, 47% were highly satisfied with the use of particular method, while almost one-third (32.0%) were somehow satisfied and 21% were unsatisfied ( Figure 2). The highly satisfied group is comfortable with the method without reservation. Somehow satisfied are happy with the method but would like a better method or an improved version if available due to the side effects of the current method or difficulty associated with its use.
This study found the age group of female head-porters (p = 0.005), marital status (p < 0.0001), and religion (p = 0.029) to be significantly associated with contraceptive use among female headporters (Table 3)   F I G U R E 2 Level of satisfaction with contraceptive use among female head-porters. The highly satisfied are comfortable with use of method without reservation. The somehow satisfied are happy with current method but will prefer another method or an advanced form of the method in use due to side effects or difficulty associated with its use.

| Influence of sexual and reproductive factors on contraceptive use
first sex (p = 0.033) were significantly associated with contraceptive use among female head-porters.

| LIMITATIONS
The study has no controlled group. Moreover, data were collected by both convenience sampling and consecutive recruitment due to the absence of a formal sampling frame for study participants. There are also missing data for certain variables largely because certain information could not be ascertained from study participants.

ACKNOWLEDGMENTS
The authors are grateful to all research assistants and volunteers who contributed in diverse ways for successful implementation of the study.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All data generated or analyzed during this study are included in this article and its Supporting Information files and can be requested from the corresponding author.

ETHICS STATEMENT
The study was approved by the Committee on Human Research,